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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

May 2014

Hetlioz Now Covered with Prior Authorization 

In January, the FDA approved the medication Hetlioz, a melatonin receptor agonist, to treat non-24-hour sleep-wake disorder. This medication is now available through Harvard Pilgrim’s specialty pharmacy program with prior authorization.  It will be covered at Tier 3 for 3-Tier formulary and Tier 4 for 4-Tier formulary.

Prior authorization is required to ensure that Hetlioz is used only for its FDA-approved indication (non-24-hour sleep-wake disorder) and in the appropriate dosage (1 20-mg capsule per day at bedtime). Approvals will be for 1 20-mg capsule per day for a 12-month period.

To obtain prior authorization, please refer to the Hetlioz Clinical Criteria, and complete the appropriate Medication Request Form and fax it back to MedImpact Healthcare Systems at 888-807-6643.

Hetlioz will be offered through the specialty pharmacy Accredo. For more information, please visit Harvard Pilgrim’s pharmacy page.

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Eric H. Schultz,
President and Chief Executive Officer

Richard Weisblatt PhD,
Senior Vice President, Provider Network

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Production Coordinator